Month: September 2014

Women have long been familiar with the benefits of pelvic floor strengthening exercises, colloquially referred to as “Kegels,” in honor of Dr. Arnold Kegel, the individual who first described them in 1948. Almost any woman who has ever been pregnant has been told by her doctor, sister, or friend to engage in Kegel exercises to help strengthen the muscles that get stretched and weakened during the nine months of pregnancy and during labor and delivery. However, recent conversation in the International New York Times (Pelvic Exercises for Men, Too, July 14, 2014) has turned to the benefits of Kegel exercises for MEN. Author Roni Caryn Rabin describes how pelvic floor strengthening benefits men with urinary incontinence and possibly even sexual dysfunction. Research has shown that Kegels are helpful for men who experience premature ejaculation, and they may possibly help men with erectile dysfunction. Rabin interviews urologist Dr. Andrew L. Siegel, creator of a pelvic floor muscle strengthening system for men called Private Gym. The system utilizes light weights attached to a silicone band that is placed on the penis to provide resistance training to the pelvic floor muscles. Dr. Patricia Goode, medical director of the incontinence clinic at University of Alabama, participated in research in 2006 which proved that Kegels help restore continence in men after radical prostatectomy. In fact, the results are startling- the group who participated in Kegels post-surgery were ALL, on average, fully continent within 3.5 months compared to the control group (no Kegels performed), HALF of whom were not continent after SIX months. So, men, I challenge you to join your lady friends and join the Kegel club! If you have no idea how to perform a pelvic floor muscle contraction or have any questions about pelvic floor health, we here at Beyond Basics are happy to assist! Please let us know if there is anything we can do to help.

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So, how does physical therapy help treat lymphedema? Great question, I am glad you asked. The gold standard of care to treat lymphedema is COMPLETE DECONGESTIVE THERAPY (CDT). CDT consists of four components:

Manual Lymphatic Drainage (MLD)

Compression

Exercises

Skin Care

MLD was pioneered by Dr. Emil Vodder in the early 1900s, and it is series of various manual techniques (including “pump,” “rotaries,” “scoop,” “and pump-push,” to name several) which promote moving the excess lymph fluid from the distal extremities towards proximal, healthy open lymph channels. Another way to think about lymphedema due to lymph node removal is that there is congestion on one “road”. Therefore, the certified lymphedema therapist (CLT) seeks to open up and create new channels on uncongested “roads,” thereby creating detours for the lymph to return to the venous system through alternate routes. MLD allows the CLT to direct the lymph along healthy, open lymphatic pathways.

In addition, appropriate compression must be applied to promote the return of lymphatic fluid and to prevent it from improperly pooling in affected areas. Therefore, compression is an appropriate component of CDT. During the acute first phase of treatment, bandaging should ideally be worn 23 hours during the day and removed only for showering or bathing. CLT therapists bandage patients with short stretch bandages and they teach patients how to perform self-wrapping. During the chronic second phase of treatment, compression garments can be substituted for bandages during the day, either custom made or over the counter. Bandaging is continued for nighttime usage in most cases.

No physical therapy experience would be complete without some exercise, right? Exercises are important in treatment of lymphedema because the musculoskeletal system helps with venous return and promoting fluid movement by acting as a pump mechanism. That’s why ankle pumps (ankle dorsiflexion and plantarflexion) are recommended after ankle surgeries, in treatment of postsurgical edema (swelling). So too, similar upper extremity and lower extremity “pump-like” exercises help return lymphatic fluid to the venous system. Depending on the type of lymphedema (upper vs. lower extremity) several examples of lymphedema appropriate exercises include ankle pumps, knee and hip flexion and extension, shoulder flexion and abduction, elbow flexion and extension, and wrist flexion and extension.

Finally, skin care is a huge component of CDT. The reason for this is that increased swelling of any extremity increases the DIAMETER of the extremity. This increases the distance that gases (ex. oxygen) and nutrients must travel to reach the surface of the skin. This is referred to as increased diffusion distance. Oxygen is a necessary component in skin healing after any injury, even simply a paper cut! It is harder for oxygen to travel long distances compared to short distances, therefore increased diffusion distance (as in the case of lymphedema) SLOWS the healing process. Slower healing rate increases the likelihood of developing an infection through the open wound. Therefore, it is crucial for all patients with lymphedema to be vigilant about skin care and inspection. Their wounds heal slower than those of other individuals, and it is important to minimize the chance of developing infection by keeping wounds clean and covered.

So there you have it! That was a brief overview of “How I Spent My Summer Vacation.” I could not think of a better way to spend my time this summer. Don’t get me wrong, a week in Italy or an Alaskan cruise are trips that I look forward to hopefully taking one day, but I am grateful that I had the opportunity to take this incredible course his past summer. This course is rarely offered in New York, so I had to jump on my chance when I saw it advertised. Thank you to Amy for supporting my continuing education and to my co-workers for helping to treat my patients while I was at the course. Italy and Alaska can wait for me, because my patients are more important!

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Background complete- you have made it through the anatomy, good job! Time to discuss the PATHOPHYSIOLOGY. Unfortunately, things don’t always run as smoothly and perfectly as we just described, and dysfunction of the lymphatic system can result in LYMPHEDEMA. Lymphedema (LE) is swelling of the upper or lower extremities due to impairment in the lymphatic system. It can also develop in the trunk, head, neck, or genitals. It is a chronic disease and treatment involves lifetime management of the condition.

There are two types of lymphedema, primary and secondary. Certain individuals are born with a congenital malformation of the lymphatic system, (ex. the vessels are too large or too small). This is known as PRIMARY LYMPHEDEMA.

Furthermore, an initially healthy lymphatic system can develop problems through infection, obstruction, or damage. This is known as SECONDARY LYMPHEDEMA. Globally, the most common cause of lymphedema is filariasis, a parasitic disease that is caused by thread-like roundworms which occupy the lymphatic system, including the lymph nodes. The worms enter the lymphatic system through blood feeding mosquitos and black flies in certain tropical countries.

In the United States, the most common cause of lymphedema is breast cancer-related surgeries that involve removal of affected axillary lymph nodes. Removal of lymph nodes results in impairment in the lymphatic system, and it disrupts the normal return of fluid to the venous angles. This can result in swelling of the involved upper extremity. Similarly, lower extremity lymphedema can develop after removal of pelvic and or inguinal lymph nodes (ex. due to prostate or gynecological cancer surgeries).

Lymphedema can develop days, weeks, months, or even years after surgical node removal. Therefore, individuals who have undergone these types of surgeries should be aware of their predisposition towards developing the disease. Any abnormal swelling or changes should be reported to one’s physician immediately, because the prognosis is better if the disease is detected and treated earlier.

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Approximately 10% of water that exits the capillaries and enters the interstitial space at the arterial end of the capillary does NOT return at the venous end due to pressure related factors (refer to Starling’s Equation for more details). This “extra” water (referred to as the lymphatic load) enters the lymphatic system at lymphatic capillaries to the venous angles (the junction of the left subclavian vein and the internal jugular vein). The lymphatic system meets the circulatory system at the venous angles, and it is where the extra water is returned to the circulatory system.

Furthermore, certain molecules, including fats from the digestive system and certain large proteins, are TOO LARGE to travel through the narrow diameters of the circulatory vessels. Instead, they travel through the larger lymphatic vessels along with the water.

Now, moving on to the title of this blog…It would be impossible to explain the lymphatic system without mention of our ever so crucial LYMPH NODES. Lymph nodes are small oval shaped organs that contain white blood cells, T cells, and B cells which are responsible for fighting infection and are a component of the immune system). All lymph fluid travels through a series of lymph nodes, which are also responsible for filtering the lymphatic fluid. There are approximately 600 lymph nodes in the average adult human body.

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Can you believe that Labor Day has come and gone? Yes, dear readers, summer is officially over. But boy, was it an amazing and memorable summer!

Believe it or not, when asked about the highlight of my summer, I unequivocally and enthusiastically respond that it was my lymphedema certification course. (#PTnerd. And darn proud of it too). Fortunately, I had the wonderful opportunity to return to class this summer and learn some pretty incredible, stimulating, and practical material. Touro College, right here in New York City, hosted a course taught by The Academy of Lymphatics, one of the highly recognized training centers in the world of lymphedema. The course was an intensive nine day class which was three classes condensed into one. In addition, each participant was required to complete seven modules which included extensive textbook reading. Each module contained a written online examination which we were required to complete prior to attending the class. I found this approach extremely beneficial, because it allowed me to begin with a strong foundation.

The course itself was fascinating! The instructor, Marina Maduro, and her assistant, Kirat Shah, are excellent educators who were clearly well versed in the material and who explained difficult concepts well. I would be one to know; let’s just say I am not shy when it comes to asking questions, and I challenged them on many a concept that they clarified and explained clearly.

You are probably wondering, okay Riva, so what did you ACTUALLY learn, in a nutshell, in this course? Let’s start off by first discussing the lymphatic system itself. I like to call the lymphatic system “the secondary circulatory system.” It is an OPEN system without a central pump. The primary circulatory system, which consists of the heart, blood vessels (arteries, veins, and capillaries), are responsible for transporting fluids, nutrients, gases, and waste products throughout the body. It is a CLOSED system with a pump (the heart)…

To learn more, stay tuned for my next post!

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Thank you for following the Beyond Basics Blog. I hope that you enjoy READING the blog posts as much as I enjoy WRITING them! I strive to talk about topics that interest you. That being said, I cordially invite you to submit questions that you have regarding the pelvic floor and I encourage you to share ideas that YOU want to learn about. Are there any burning topics that you wish I discussed in greater detail? Do you have any questions in particular that I can help answer? Have you heard about any innovative treatments or new research that spark your curiosity?

I would love to hear YOUR VOICE and know your interests. Consider this an opportunity to “choose your own adventure”, so to speak, in the world wide web of blogs. I am happy to hear your suggestions and aim to please, so don’t be shy! It is my pleasure to respond and discuss matters that matter to you!